I decided to become an orthopaedic surgeon during my junior year of medical school. Orthopaedics seemed entirely different from other specialties. The surgeons, with their saws, chisels, and hammers, looked like carpenters and the surgical procedures looked like a mechanics class. The language was unique, seemingly designed for mechanical engineering. I was drawn to the independent nature of orthopaedic surgery; patient care could be conducted without much reliance on other specialties. The uniqueness of orthopaedic surgery—with its broad scope of practice—required visual demonstration and hands-on workshop courses. I just fell in love with the idea of treating patients in this unique way.
But in the Asia-Pacific region, particularly China, India, and Korea, orthopaedic surgeons typically treat more patients in clinic than physicians in other surgical specialties [5, 9]. For example, in a typical half-day clinic, I routinely see more than 100 patients. Learning how to handle a patient load of this magnitude with safety, accuracy, and efficiency is not something that is taught—or can be learned—in the classroom.
Algorithmic Approach in Clinic
In an extremely busy clinic, making the correct diagnosis in such a short period of time is challenging. An algorithmic approach that reflects the prevalent diseases relevant to the particular clinic or region is an efficient way to facilitate the care process, allowing the clinic's staff to spend more time on patient care and administrative work.
In my practice, where I generally see patients with knee issues, I have established a three-step algorithmic approach that works for my office: (1) Identify why the patient is visiting the clinic. Is this a first visit or a return? (2) Review medical records. Collect history, physical findings, imaging studies, and laboratory tests. (3) Decide what to do for the patient—further evaluate, assure and discharge, or make a diagnosis (Fig. 1).
In order to make a diagnosis, the surgeon needs to be aware of any conditions or diseases prevalent to their region. Disease or symptom patterns vary within each region. For example, the presence of varus deformity, which is much more frequent in the Asia-Pacific region than in other regions [8, 10, 11], is an important factor to consider when identifying the underlying causes for symptoms or conditions , or predicting disease progression and making treatment plans [7, 15].
By using the algorithmic approach, we can quickly determine how to manage the patient on that day, allowing for more discussion time on treatment options and addressing any patient concerns.
Lean on Mentors
With such a high volume of patients, inevitably a physician will come across a patient who is dissatisfied with their results, and may elect to pursue a legal path. In my previous column , I discussed how a warm and compassionate approach to treating patients could remedy or resolve disputes between patients and physicians before they reach the courts. Still, disputes with patients—resolved or not—can increase the physician's stress level. Many studies suggest that “burnout” is common among orthopaedic surgeons around the world [1, 13, 14] and Asian surgeons are no less vulnerable to stress. Mindfulness-based practice and emotional support from a colleague or mentor can help surgeons cope with the high-stress working environment [3, 12] or legal obligations.
Young surgeons are a byproduct of those who came before them. Mentors have the experience to show young surgeons how to maintain a work-life balance, how to treat patients in a busy clinic, and how to always stay focused on the mission—helping patients get better.
Broadly speaking, there is a large difference in the mentorship patterns between the Asia-Pacific region and the West. While teaching in the Western world is more target-specific and professional, the mentor-protégé relationship in the Asia-Pacific region involves a greater personal touch. Although there is a certain hierarchy in the Asian work culture, which to some extent, limits the natural flow of knowledge and information between the two, the mentors are revered by their students in Asian countries and are looked upon with greater respect and privilege. A mentor should be a strong pillar of support in every adverse situation, including professional or personal stresses or dealing with patient issues at outpatient clinics.
Running a Business
Seeing 100 patients in a given day is more than enough work for an orthopaedic surgeon. However, the day rarely ends when the last patient leaves the clinic. It is quite common in Asian-Pacific regions for the orthopaedic surgeon to be in charge of the business side of the clinic as well. Healthcare systems vary substantially among countries in Asia, a fact that has important implications to the surgeon in charge of a clinic or hospital. The surgeon must be knowledgeable and updated of pertinent business-related issues, particularly reimbursement systems. Surgeons who act as the practice's de facto chief executive officer should have or be given a proper education on business management and human resources. They should consider attending formal educational courses or seeking in depth advice from senior physicians who are experienced in these matters.
In many instances, our family's healthcare is in the hands of today's young surgeons. How young physicians cope with this massive responsibility will depend on whether they are prepared for the patient load, have a mentor they can count on, and have a diversified education. If young surgeons can obtain all of those characteristics, they will find their job rewarding and meaningful—no matter the patient load.
That is how you stay in love with orthopaedic surgery.
I would like to conclude by quoting a spiritual and inspiring poem by Korean Buddhist monk, Cheong Heo.
When walking across a snow-covered field,
May you stay mindful and wary of chaos.
For the footsteps you take today,
Shall serve as a milestone for others tomorrow .
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